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Overview

Skin cancer is the most common type of cancer, probably making up more than half of all diagnosed cases of cancer, according to the American Cancer Society (ACS). The incidence of skin cancer is rising dramatically in the United States. About 3.3 million cases of non-melanoma are diagnosed each year, leading to about 3,000 deaths. And the ACS estimates that in 2016, there will be 76,380 new cases of melanoma and 10,130 deaths from the disease. In fact, between 40 percent and 50 percent of people in the United States over age 65 will develop non-melanoma skin cancer. This type of cancer is highly treatable when diagnosed in its early stages and is usually relatively easy to diagnose.

The majority of lifetime sun exposure occurs before age 20, and skin cancer can take 20 years or more to develop. In fact, very young children who experience as few as two to three severe sunburns are believed to have an increased risk of developing skin cancer later in life. That's not to say you should ignore your risk of developing skin cancer. You need to be concerned about skin cancer, whether your sunbathing days are over or you still spend time pursuing the perfect tan.

The Structure of Skin

The skin is the largest organ in your body and is the body's first defense against disease and infection. It also protects your internal organs from injuries. The skin regulates body temperature, prevents excess fluid loss and helps to remove excess water and salt from your body.

Skin is composed of two layers: the epidermis (the outermost layer of skin) and the dermis (the lower layer). The epidermis itself has four layers: the stratum corneum, the granular layer, the squamous cell layer and the basal cell layer. Keratin (dead, dense protein cells) makes up the stratum corneum or outer layer of the epidermis—the skin layer that can be seen and felt.

The granular layer moves the dead keratin cells to the surface of the epidermis. The squamous cell layer produces keratin for the stratum corneum and also transports water. The basal cell layer is the lowest layer of the epidermis. This is where squamous cells are produced and where the cells that produce melanin, or skin pigment, reside.

The dermis is the deeper layer of skin. It is a diverse combination of blood vessels, hair follicles and sebaceous glands or oil glands. The proteins collagen and elastin are found in the dermis. They provide support and elasticity to the skin. The sun's rays eventually break down these proteins. With age, the skin naturally begins to wrinkle and sag.

The subcutaneous level, or subcutis, is a layer of fatty tissue that provides nourishment to the dermis and upper layers of skin. It also conserves body heat and cushions internal organs against trauma. Blood vessels, nerves, sweat glands and deeper hair follicles are found here.

Types of Skin Cancer

There are two main groups of skin cancer: non-melanoma skin cancer, the most common type of skin cancer, and melanoma (sometimes referred to as "malignant melanoma") skin cancer.

According to the ACS, basal cell carcinoma makes up 80 percent of non-melanoma skin cancers, and squamous cell carcinomas account for about 20 percent. About 5.4 million cases of non-melanoma skin cancer are diagnosed every year in the United States. Men have a higher risk than women of developing these skin cancers.

Melanoma is the least common, but most aggressive, of the three types of skin cancer. It originates in the skin's melanocytes—the cells that produce pigment, or melanin.

In 2016, the ACS estimates that 76,380 new cases of melanoma will be diagnosed in the United States—about 1 percent of all diagnosed skin cancers. But melanoma accounts for the vast majority of skin cancer deaths. One person dies of melanoma almost every hour (every 52 minutes).

Risk Factors

Anyone can develop skin cancer, but people with fair complexions are more susceptible to precancerous conditions and skin cancer than people with darker skin tones. That's because darker skin has more melanin, which provides some natural protection against the sun's damaging rays. In addition to fair skin, other risk factors for skin cancer include:

a personal history of skin cancer

a tendency to freckle or burn easily

lots of sun exposure throughout your life

many sunburns as a child or adolescent

family history of the skin cancer or conditions that are more likely to develop into skin cancer

chronic, non-healing scarring

radiation therapy

exposure to toxic materials, such as arsenic, coal tar or creosote

exposure to certain subtypes of human papillomavirus (genital warts) especially in people with compromised immune systems

Health care professionals are able to evaluate many skin abnormalities. A primary care physician should be the first health care professional you see if you notice something suspicious on your skin. Then you might consult with a dermatologist, a physician with extensive training in skin care and skin disorders, particularly skin cancer.

The first step in detecting abnormalities that may be skin cancer begins with you. Examine your skin once a month for any suspicious changes. Look for changes in color, size and surface texture of a mole. Sores that won't heal may also indicate cancerous or precancerous conditions of the skin that need attention.

Actinic keratoses. This precancerous condition typically occurs in people with a long history of sun-damaged skin. Lesions appear as rough, crusty bumps on the back of the hands, lips, face, scalp or neck that may itch or feel tender on sun-exposed skin. They may be pink or white. If untreated, these bumps may develop into skin cancer. They affect an estimated 58 million Americans and are usually more prevalent in people over 40 and in sunnier climates. However, they may show up earlier in people who have used tanning beds or sun lamps.

Basal cell carcinoma. Basal cell carcinoma show up as flat, firm, pale areas or as small raised pink or red pearly bumps that may bleed after minor injury. These bumps or growths may appear anywhere on the body regularly exposed to the sun, such as the head and neck. They are slow growing and rarely spread to other parts of the body. But they can extend deep into the skin, causing significant local damage. Approximately 80 percent of all basal and squamous cell skin cancer cases diagnosed annually are basal cell carcinoma. This form of skin cancer has a high cure rate. However, if left untreated, basal cell carcinoma can result in disfigurement.

Squamous cell carcinoma. The second most common non-melanoma skin cancer, squamous cell carcinoma, appears as nodules or as red, scaly patches, typically on the ears, the face, the lips and mouth. These patches eventually develop into large masses. According to the Skin Cancer Foundation, more than one million cases of this type of cancer are diagnosed each year, leading to about 8,800 deaths. This type of skin cancer is slightly more likely than basal cell carcinoma to spread to other parts of the body. But it is also highly treatable.

Melanoma: Melanoma can develop from a preexisting mole or on clear, smooth skin. Unlike a noncancerous mole, melanoma is irregularly shaped or has irregular borders, and is black, brown or tan. It can also look like a pink or white bump and be called "amelanotic." Melanoma is rare in childhood and adolescence, but it is one of the more common cancers in younger adulthood and middle age. It is especially prevalent in late middle and older age. The leg is the most common site in women, and the trunk is the most common site in men. Early diagnosis is key to improving the prognosis in this potentially fatal disease.

It is important to remember the "ABCs" of melanoma. The AAD has developed an easy-to-use method to evaluate your skin for melanoma. Look for:

Color: Shades of tan, brown, black, and sometimes red, white and blue, vary across the mole.

Diameter: The spot is larger than six millimeters, about the diameter of a pencil eraser. However, in recent years, health care professionals are finding more melanomas between three and six millimeters.

Evolving: The mole or skin lesion looks different from the rest or is changing in size, shape or color.

Excessive sun exposure causes the majority of melanoma. A family history of the disease is also a major risk factor. Individuals with a family history of melanoma, or who have had melanoma in the past, may need to see a dermatologist regularly in addition to performing self-examinations. Talk to your dermatologist about how often you should be professionally screened. To learn how to effectively perform a self-examination, visit The Skin Cancer Foundation https://www.skincancer.org/early-detection/self-exams/

Other types of skin cancer: Less common types of skin cancer, which together make up only 1 percent of all cancers, include:

Kaposi's sarcoma. This form starts in the blood vessels of the dermis and subcutaneous layers and can affect internal organs. Prior to the middle 1980s, this skin cancer was very rare. But since it often afflicts people infected with the human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS), it has become more common.

Sarcomas. These are cancers that form in the cells of your connective tissues but occasionally they begin in the dermis. Angiosarcoma, a blood vessel cancer, is one example.

Cutaneous lymphomas. These skin cancers originate in the skin's lymphocytes, which are immune system cells found in the bone marrow and blood. The most common cutaneous lymphoma is cutaneous T-cell lymphoma, also called mycosis fungoides. It appears as red, scaly patches and can resemble eczema or fungus.

Adnexal tumors. These are typically benign tumors that originate in the hair follicles and sweat glands. Occasionally they can be malignant.

Merkel cell carcinoma. This rare cancer begins in the skin's neuroendocrine cells. It usually develops in people who've had a lot of sun exposure and may also have a compromised immune system. It was recently discovered that Merkel cell carcinoma is caused by a specific virus. It frequently returns after treatment and can spread to internal organs and lymph nodes.

Diagnostic Tests

To determine if your skin abnormalities are skin cancer, your dermatologist may perform a biopsy: taking a sample of skin to examine under a microscope. After receiving a local anesthetic, you may feel some minor discomfort—a small needle stick, burning and pressure. There are four primary types of biopsies:

Shave biopsy. The top layers of skin, the epidermis and a part of the dermis are shaved off in a thin slice.

Punch biopsy. A deeper, cylindrical core sample of the skin layers and part of the fat layer is taken.

Incisional biopsy and excisional biopsy. A wider, deeper sample of all your skin layers is taken, then the skin is sutured with stitches. Incisional biopsies remove a portion of the tumor and excisional biopsies remove the entire tumor.

Biopsies of cancer that has spread. In some cases, biopsies of areas other than the skin may be necessary. To find out if—and where—a skin cancer has spread, your health care professional may use one or more of the following tests:

Fine needle aspiration biopsy. Using a fine needle to remove very small tissue fragments, fine needle aspiration (FNA) biopsy may be used to biopsy large lymph nodes near a melanoma to find out if the melanoma has spread.

Surgical (excisional) lymph node biopsy. If a lymph node's size suggests melanoma has spread but an FNA biopsy doesn't find any melanoma cells, your health care professional may remove the enlarged node through a small skin incision to take a closer look.

Sentinal lymph node biopsy. Sentinal node biopsy is typically performed for melanomas and Merkel cell carinomas beyond Stage 0. Dye is injected into the skin at the site of the tumor to identify the one or several "sentinel" lymph nodes in the region that "cleanse" that area of the skin. These few lymph nodes are then removed and carefully examined for evidence of cancer. If positive, a full lymph node dissection is usually performed.

To determine how widespread a melanoma is, your health care professional uses a system to describe its size and pervasiveness. The most common system is called the "TNM" system in which:

T stands for the "tumor"—noting the size and how far it has spread within the layers of the skin and nearby tissue.

N denotes tumor that has spread to lymph nodes.

M stands for metastasize, in which the cancer has spread to distant organs.

Using this system, melanomas are grouped according to stage. The stages are:

Stage 0. The melanoma only involves the epidermis. Also called melanoma in situ.

Stage I. This stage tumor is between 1.0 and 2.0 mm and may or not be ulcerated. It appears to affect only the skin and has not been found in lymph nodes or distant organs. This stage has a five-year survival rate of 86 percent to 95 percent.

Stage II. A tumor with any thickness greater than a stage I tumor that appears to affect only the skin and has not been found in lymph nodes or distant organs. This stage has a five-year survival rate of about 40 percent to 67 percent.

Stage III. A melanoma that has spread to lymph nodes near the skin where it originally began. This stage has a five-year survival rate of about 24 percent to 68 percent.

Stage IV. A melanoma that has spread well beyond the originally affected skin and the nearby lymph nodes. It has metastasized to vital organs or to distant areas of the skin or distant lymph nodes. This stage has a five-year survival rate of 15 to 20 percent.

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Treatment

There are several treatments your dermatologist may prescribe for actinic keratoses (precancerous lesions) or skin cancer:

Photodynamic therapy, which involves applying a chemical that makes the skin more sensitive to light and then using an intense laser to destroy damaged skin cells

Immune response modifiers, These drugs are given internally to boost the immune response against the cancer, causing it to shrink and disappear.

Curettage and electrodessication. A sharp instrument resembling a vegetable peeler called a curette is used to scrape away the cancer, and an electric current or needle burns the borders of the site where the tissue was removed.

Simple excision. The cancer is cut from the skin along with some of the healthy tissue around it. This may scar your skin, so sometimes skin is taken from another part of your body and grafted over the area where the cancer was removed.

Mohs micrographic surgery. This surgical technique has a better success rate than other techniques, but it is also more complex and time consuming. It is used especially when the borders of the cancer are not obvious. The procedure, which is usually performed in the surgeon's office on an outpatient basis, removes the cancer and as little normal tissue as possible. The surgeon then uses a microscope to examine the borders of the removed tissue to ensure no cancer cells remain.

Lymph node surgery. If the lymph nodes near a non-melanoma skin cancer are growing larger, those nodes may be biopsied or removed and examined under a microscope for signs of cancer. This procedure is more involved than skin surgeries and usually requires general anesthesia.

Skin grafting and reconstructive surgery. If a surgically removed non-melanoma skin cancer was large, the nearby skin may not stretch far enough to close the wound. In a case like this, healthy skin may be taken from another part of the body and grafted over the wound to help with healing.

Radiation. For tumors that are hard to treat with surgery, or with those that occur in elderly people or those in poor health, treatment may include radiation. During radiation treatments, x-ray beams are directed at the tumor. Radiation treatment usually requires several treatments over a few weeks or daily treatments for one month. Cure rates are around 90 percent.

Oral medication. For locally advanced or metastatic basal cell skin cancers, treatment may involve medications taken orally. Vismodegib (Erivedge), approved in 2012, works by stopping the "hedgehog" signaling pathway—a key step in the development of basal cell carcinoma. Another hedgehog inhibitor called sonidegib (Odomzo) was approved in 2015.

For melanomas:

Surgery. Most melanomas are surgically removed with a layer of healthy surrounding skin, the size of which is based on the thickness of the melanoma tumor under the microscope (determined during the biopsy). A specific type of surgery called Mohs surgery is sometimes used to treat ill-defined shallow melanoma tumors in the head and neck area.

Lymph node dissection. During this procedure, the surgeon removes all of the lymph nodes in the region of the melanoma. Once a diagnosis of melanoma is made, the physician will examine the lymph nodes closest to the melanoma, either by physical examination or imaging tests. If the nearby lymph nodes feel abnormal and a fine needle aspiration or excisional biopsy reveals the melanoma has spread, a lymph node dissection will most likely be done.

Immunotherapy. Immunotherapy uses substances produced by the body or similar substances produced in a laboratory to stimulate the immune system to help the body fight cancer. This treatment is typically used for melanomas that are very thick or when lymph nodes are involved. Specific therapies include ipilimumab (Yervoy), pembrolizumab (Keytruda), nivolumab (Opdivo), interferon and interleukin-2 (IL-2). Side effects of these treatments include headache, chills, fever, fatigue and muscle aches.

Targeted therapy. Targeted therapies use substances to identify and attack specific types of cancer cells or to block genes, proteins, or enzymes that can help cancer cells grow and spread. These therapies treat cancer cells without affecting healthy cells. They include vemurafenib (Zelboraf), dabrafenib (Taflinar), and trametinib (Mekinist).

Oral or injected chemotherapy. Chemotherapy is the use of medicines to slow or stop the growth of cancer cells. In the case of melanoma, chemotherapy is typically used for metastatic disease to shrink tumors. The most common chemotherapy drug used for melanoma is dacarbazine (DTIC). It may be given with carmustin (BCNU) and tamoxifen, or with cisplatin and vinblastine. The drug temozolomide (Temodar), an oral pill, may also be given. It acts similarly to DTIC. Temozolomide is FDA-approved for brain cancers and used off-label for melanomas that have spread to the nervous system or brain. Physicians give chemotherapy in cycles, with a period of treatment followed by a period of rest to allow the body to recover. Each cycle typically lasts for a few weeks. Side effects of these drugs include nausea and vomiting.

Radiation therapy. Radiation is usually used to prevent recurrence or for melanomas that have come back or spread to other organs.

Prevention

About 90 percent of all skin cancers could be prevented by protecting yourself from the harmful rays of the sun.

Sunlight consists of two types of ultraviolet (UV) rays that damage skin—UVA and UVB rays. UVC rays, another spectrum in sunlight, are also potentially harmful, but the ozone layer blocks most of them from reaching the earth. UVA and UVB rays are present all year and are hazardous, whether they are direct or reflected. When the sun's ultraviolet radiation reaches the surface of the skin, the skin reacts by producing melanin—otherwise known as a tan—to protect itself.

UVB rays are the main cause of sunburn and skin cancer. This type of sunlight intensifies during the summer and damages skin more quickly than UVA rays. The epidermis absorbs most of the intensity of UVB rays. The rays are strongest between 10 a.m. and 4 p.m., which is when the skin is most likely to burn.

UVA rays have a longer wavelength and penetrate deeper through the skin's layers. UVA rays also penetrate through glass and are present on cloudy days and all year round, even early and late in the day. UVA rays contribute to wrinkling of the skin and immunosuppression, as well as the development of skin cancer. They are also responsible for tanning.

UVA rays also are used in tanning booths. There, they not only inflict the same type of skin and eye damage as the sun, they may be as much as 12 times stronger than natural sunlight, depending on the bed.

To screen for skin cancer, ask your health care professional to examine your skin carefully as part of a routine cancer-related checkup. You should also examine your own skin for abnormalities, preferably once a month. If you find anything suspicious, make an appointment with your health care professional.

Minimize Total Sun Exposure

For the best protection from the sun's harmful rays:

Stay in the shade whenever you can.

Limit the time you spend in the sun.

Wear sunscreen at all times, especially between 10 a.m. and 4 p.m., when the burning rays are strongest.

Be aware that the sun's ultraviolet (UV) rays can reflect off water, sand, concrete and snow, and can reach below the water's surface, as well as burn on an overcast day.

Wear a large-brimmed hat and sunglasses to protect your scalp and eyes.

Wear a cool, long-sleeved shirt and long pants with a tight weave (or made of material especially designed for sun protection) whenever possible.

Select a broad-spectrum sunscreen, which protects against both UVA and UVB rays. Apply sunscreen with an SPF of 30 or higher 15 to 30 minutes before sun exposure, with careful attention to sun-exposed areas such as the face, hands and arms.

Apply lip balm with an SPF of 30 or higher to protect sun-sensitive lips.

Reapply about an ounce (the size of a shot glass) of sunscreen at least every two hours, more frequently if you've been swimming or sweating.

Be particularly cautious if you're taking an antibiotic or other medication that can make your skin more sensitive to the sun. Nonsteroidal anti-inflammatory drugs like aspirin, ibuprofen (Advil) and naproxen (Aleve) are common drugs that can make the skin more sensivite.

Nothing is as effective at reducing your risk of skin cancer as avoiding the sun or using physical "screens" such as umbrellas, broad-brimmed hats and long-sleeved shirts. However, sunscreens should also be an important part of your daily skin health routine because they absorb ultraviolet (UV) rays.

The American Academy of Dermatology (AAD) recommends you look for the following in a sunscreen:

Broad-spectrum protection (protects against both UVA and UVB rays)

A sun protection factor (SPF) of 30 or higher

Water resistance

The FDA is continuing to study spray products to establish levels of effectiveness and to see if there's any danger from accidental inhalation. Until that information is available, if you (or your kids) prefer the spray sunscreens, be sure to use a lotion on and near your face and apply the spray generously to the other parts of your body.

To help ensure the safety of sunscreens, Congress passed the Sunscreen Innovation Act (SIA) in 2014. The SIA created a new process for the review of safety and effectiveness of nonprescription sunscreen active ingredients.

Remember, any sunscreen not labeled as "broad spectrum" or that has an SPF value between 2 and 14 may only help protect against sunburn (and even there, your protection is minimal). These products must carry a "Skin Cancer/Skin Aging Alert" to remind you that you are not protected against skin cancer or early skin aging.

If you develop a rash or other type of allergic response to a sunscreen, try a different brand or form (lotion vs. oil, for example) to see if you can better tolerate it. Sunscreens containing higher levels of SPF tend to stay on the skin longer. Gels wash off more easily and need to be reapplied more frequently, but may be preferable if you are acne-prone or have sensitive skin.

Lotions, oils, gels and creams can all be effective sunscreens, but all sunscreens should be reapplied after water contact and sweating.

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Facts to Know

The most serious consequence of sun exposure is skin cancer.

Skin cancer is the most common type of cancer.

Skin cancer can take 20 years or more to develop.

Anyone can develop skin cancer and precancerous conditions, although people with fair complexions tend to be more susceptible than people with darker skin tones.

Although African Americans are diagnosed with melanoma less often than whites, they have a higher death rate from the disease. According to the Skin Cancer Foundation, the overall survival rate for African Americans is 70 percent, compared to 93 percent in whites.

The earliest warning sign of severe skin damage is the development of actinic keratoses—rough, crusty bumps on sun-exposed areas that may itch or feel tender when exposed to sunlight. According to the Skin Cancer Foundation, actinic keratoses affect more than 58 million people in the United States and are becoming more common.

There are two main forms of skin cancer: non-melanoma and melanoma—often referred to as "malignant melanoma." Several other very rare types of skin cancer exist but account for less than one percent of all skin cancer cases.

Basal cell carcinoma and squamous cell carcinoma are the most common types of non-melanoma skin cancer, affecting approximately four million each year, according to the Skin Cancer Foundation. These cancers are slow growing and rarely spread to other parts of the body.

Melanoma is the least common, but most aggressive, of the three main types of skin cancer. The American Cancer Society predicts that there will be about 76,380 cases of melanoma diagnosed in 2016. Melanoma accounts for about 1 percent of all diagnosed skin cancers—but it accounts for the majority of skin cancer deaths.

The sun's UVA rays contribute to wrinkling and burning of the skin, as well as to the development of skin cancer. UVA rays are also used in tanning booths where they may be up to 12 times stronger than natural sunlight, depending on the bed.

Questions to Ask

Review the following Questions to Ask about skin cancer so you're prepared to discuss this important health issue with your health care professional.

Am I at high risk for skin cancer now?

What can I do to minimize my risk?

What should I look for when examining my skin?

How often should I examine my skin?

What should I do if I find a suspicious spot on my skin?

What is the best type of sunscreen for my skin?

If my skin abnormality is cancerous, what treatments are available?

What other treatment options do I have?

What type of health care professional will treat this condition?

Could other family members be at risk for this type of skin cancer?

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Key Q&A

Are tanning beds safer than the sun?

No. Tanning beds use UVA rays. They may not only inflict the same type of skin and eye damage as the sun, but may also be as much as 12 times stronger than natural sunlight. Although UVA rays are milder than UVB rays—the main cause of sunburn and sun cancer—UVA wavelengths are longer and they penetrate deeper through the skin's layers. UVA rays contribute to wrinkling the skin, as well as to the development of skin cancer.

If someone in my family has had skin cancer, does this increase my risk for developing the disease?

Yes. Although sun exposure is responsible for most cases of melanoma, a family history of the disease can also be a risk factor. You are especially at risk if other members of your immediate family have had melanoma. People with atypical moles (nevi) are also at higher risk for developing melanoma. Individuals with a family history of melanoma, or who have had melanoma in the past, may need to see a dermatologist regularly in addition to performing self-examinations. Talk to your dermatologist about how often you should be professionally screened.

Are dark-skinned people immune to skin cancer?

No. Anyone can develop skin cancer, although people with fair complexions tend to be more susceptible to skin cancer and precancerous conditions than people with darker skin tones. In addition to fair skin and light hair, risk factors for skin cancer include: a tendency to freckle or burn easily; lots of sun exposure throughout your life; sunburns as a child or adolescent; family history of the disease; history of radiation therapy; chronic scarring from diseases or burns; and exposure to toxic materials such as arsenic.

What type of SPF should I look for in a sunscreen?

Many groups, including the American Academy of Dermatology, recommend using broad-spectrum products with a sun protection factor (SPF) of 30 or higher.

While sunscreen helps minimize damaging sunburns, it doesn't completely prevent burning. The best prevention is still to minimize the total amount of sun exposure your skin receives. This includes avoiding the sun between 10 a.m. and 4 p.m., when its rays are strongest; wearing a large-brimmed hat and sunglasses to protect your scalp and eyes; covering other sun-exposed parts of your body; staying in the shade when possible; and limiting the time you spend in the sun.

My skin is sensitive and acne-prone, and sunscreen irritates it. What can I do?

If you're prone to rashes, try different brands and types of sunscreen until you find one that doesn't cause a rash. Gels wash off more easily and need to be reapplied more frequently than sunscreen lotions or creams, but they may be preferable if you are acne-prone. Discuss you skin reactions with your health care professional, perhaps a dermatologist, for other suggestions.

It's been years since I've tanned my skin. Do I still need to worry enough about skin cancer to do self-exams?

It's important to remember that your average lifetime sun exposure risk occurs before age 20, and that skin cancer can take 20 years or more to develop. In fact, very young children who experience as few as two to three severe sunburns are believed to have an increased risk of developing skin cancer later in life. So examine your skin once a month for anything unusual.

I've never had moles before, but I just noticed a brown spot on my skin. Should I be worried?

Although melanoma typically begins in or around an existing mole, it can also appear without warning on clear skin. You should bring your condition to the attention of your dermatologist for further evaluation and an accurate diagnosis.